I believe that human beings are intrinsically good and strive toward being better people, toward healing themselves, and being more whole. Just as a plant soaks up sunshine and water we humans soak up kindness, generosity, and benevolent action. The therapeutic relationship must embody this spirit of compassion for change to take place. Change is the goal of all therapy, but no single approach is right for all people. I do not do any one “type” of therapy because in my experience “one size fits all” rarely fits anybody. Occasionally, one person might fit a specific technique, but much more commonly, people are a mélange of traits and require a multitude of approaches. I bring many theories to bear and use them discerningly, depending on who you are, your history, present issues, our interpersonal dynamics, and your preferences. Your needs may change from week to week and often may change within the same session – my task is to flex with and accommodate to you, adapting to the unique demands of the therapy. Instead of focusing microscopically on internal psychological dynamics, I look at you as a whole, including physical health, career, finances, family, spirituality, etc. Just as I ask you to trust me and be vulnerable with your personal and intimate material, I trust you and respect your capacity to understand yourself and change. You have your highly unique and personal way of changing and part of my work is to foster this growth.
I find doing this work enormously gratifying because human beings naturally yearn for happiness and on some level work toward it, though sometimes in an obscured fashion. Therapy helps to deal with the obstacles on this path; at its core, psychotherapy is a reconstruction of your past and present Self, leading to a changed future Self. True change occurs not from verbal analysis or advice, but from you actively experiencing what you talk about. The psychotherapeutic environment we create is exceptional in that it allows and encourages you to manifest feelings and behaviors ordinarily experienced in the world – but with the special opportunity to observe and explore them. Although therapy is called the “talking cure”, the curative properties of therapy also require a silence that allows you to act out and say what you otherwise might not permit yourself to think. My aim as your therapist is more than just to talk to you, it is also to provide a concentrated, attuned, quiet space where you can spontaneously be in touch with your internal world. Essentially, change occurs through non-verbal (paralinguistic) communication, just as it does from the verbal. As therapy unfolds, I welcome your ongoing feedback, e.g. what you like and dislike, what’s working and what’s not, etc. This helps me understand you and your needs better, and as my understanding of you deepens, I am able to customize your therapy. If you have difficulty giving me feedback, please share your struggle or conflict with me (this is meta-level communication) and we will appropriately address it. This is an example of how therapy is seen as a microcosm and reflection of the larger world, where you may interact with the therapist in ways similar to your interaction with others. This opens up rich possibilities to explore issues as they play out in the sessions.
I do not see psychology or psychotherapy as an objective science. Client and therapist are not neutral observers testing out hypotheses with controls. We bring to the therapy our subjective views, values, perceptions, beliefs, and realities, which are evolving and dynamic. The therapy exchange is far from being rigorous and systematic as science requires. As a therapist I try to be humble, which in turn allows me to be open enough to enter another human being’s world, as different as it may be from my own. Of course, it is necessary for me to be knowledgeable about theories, interventions, and guidelines, all of which inform how I listen to and interpret your material. In promoting psychology as a science, the discipline has devised diagnostic categories based on the medical model. I must admit that as an intern thirty years ago thirty years ago, I found these diagnoses helpful for easing my anxieties about what to do with clients. It gave me an illusory sense of certainty. But over the years I’ve come to see that people do not fall into neatly circumscribed categories and there is no one prescribed treatment for a diagnosis, e.g. it’s not treating a bacterial infection with antibiotics. Instead, we humans are a beautiful and subtle kaleidoscopic mix of paradoxical colors and flavors where I need to employ artfulness borne from experience along with a sound theoretical framework in order to understand. Diagnostic labels conceal as much as reveal because they force mental filters and predispose me to biases and preconceptions . . . with diagnoses, I would not truly look at you as openly as you deserve. This is not respectful. I strive to look at you as purely and openly as you present yourself to me.
Psychotherapy does not take place in a vacuum; it is influenced by, and reciprocally influences the prevailing culture. Here again, diagnoses are fashionable or not. In Freud’s day, “hysteria” was the “it” mental illness. In the 1970’s, encounter groups and batakas were all the rage; in the 1980’s and 1990’s “repressed memory syndrome” and “multiple personality disorder” were in vogue. I am not suggesting that the diagnoses are invalid or have little clinical utility, only that the cultural, historical, and social ethos strongly intersects with the psychological zeitgeist and we therapists need to be cautious about jumping onto every passing bandwagon.
Therapy is remarkable for its complexity, reflecting the ways we write our life stories. We all struggle with the intersection between the self we know, the self we don’t want to know, the self we want to be, and the self we don’t want to be. It isn’t that we’re actively lying to ourselves (though that might be a part of it), but it’s more that we need to assemble the facts of our lives in a way we can live with. Therapy consists of re-framing our memories and life stories in favor of growth and change.
Language is central in psychotherapy because it is the medium of change in the adult client. The twenty first century heralds a view of language as discourse-based, dialectical, and meaning driven – key activities in psychotherapy. Clients’ linguistic representations in conversation create and communicate cognition, emotion, behavior, and intuition. It has been pointed out that humans are at the mercy of whatever language they use and that it is an illusion to suppose that one adjusts to Reality without language. Indeed, the “smaller world” of psychotherapeutic dialogue is built upon interpretation through language. Therapy consists of discrete acts of speech converted into expressions of immediate subjectivity whereby through discourse, the client’s personality is illuminated. Clients’ language literally reaches out to the therapist and makes itself be known. This symbiotic relationship between therapy and language is fundamental in that clients’ speech is both subject and object. Although the therapist deciphers what the client says, the purpose is not to find the “objective cause” of the problem because “truth” is fraught with subjective elusiveness; instead, the therapist listens intently to what the client says as well as to what he/she does not say – both instance are realities.
Inasmuch as language reflects human Reality, it is not a stretch to suppose that language is a key vehicle of change in therapy. Once we begin to use words as toddlers, words as symbols become such integrated parts of our experience that it becomes impossible for us to look at the world without those linguistic filters or eyeglasses to the world. We live in our creation of meanings; without language we could be trapped in living life moment by moment, without narrative, evaluation, comparison, reflection, contrast . . . without articulated self-consciousness. Without these, we would not know who we are, where we are headed, or whether or not we’ve reached there – all the stuff of psychotherapy. It is with language in therapy that the “observing ego” is created, leading to the increasing awareness and choice experienced by clients. Although we can never truly stand outside ourselves, in order to see who we are, language enables us to act vicariously “as if” such a thing were possible in creating an “observer” of yourself, where we can trust in the validity of introspection.
The crux of the therapeutic endeavor is for me to understand what you’re saying from the your viewpoint; how am I to enter your unique language world? First, I need to revere the detailed texture and mosaic of your life in order to carve out a finer life-path. Second, we need to set aside professional jargon and psychobabble, which only encourages the third pitfall of reifying clients’ language as a “thing apart.” Language is only a means to an end, where the utterance itself does not convey information to the listener. It only guides the listener in creating information for him/herself. When I listen to you, I want to see through the words to what you intend. This does not guarantee I’ll accurate grasp what you’re saying, but it does start the process of understanding. Your point of view is crucial my opening a space in which you can express who you are, a space for a form of conversation where I’ll listen to your first-person voice, and where you can communicate what it’s like to BE you, and how you experience your inner and outer worlds. To create this therapeutic climate, it’s key for me to maintain a “not knowing” or “suspended” and approach, which allows you to “make” a new autobiographical narrative rather than have one imposed by me.
Meaning in therapy does not come from dogmatic knowing based on supposition. Rather meaning is dialectically illuminated by remaining open to you with a questioning stance. The structure of your speech does not simply mirror their structure of thought because your thought does not automatically have its counterpart in words. The transition of thought to word and back again leads to meaning, where in discourse there may also be the hidden thought or subtext. So when you talk, every utterance is only an incomplete attempt to develop a fully-formed meaning. Initially, what you say and what I understand may be at odds with each other, which is why it’s necessary for the thought to be “developed” with a back-and-forth motion of checking and re-checking (thought to the word to the meaning, and vice-versa and every combination thereof). In therapy, it’s essential not just to have possibilities, but to realize them as well, just as a word realizes a thought and vice-versa. Dialogue in therapy is not just interpersonal between you and me, but intrapersonal as well, e.g. me focusing on your “inner speech” between self and self. Here I observe the manner and meaning of how you talk to yourself.
I’m prepared to learn from you, to learn what your words mean (as a portal to the world). Contrary to popular opinion, this does not require neutrality or objectivity, but instead requires me to be aware of my biases so that your discourse can reveal itself with your intentionality rather than being overlaid with my filters. In every true dialogue between you and me, in each session, we open ourselves to each other, accept the others’ viewpoint and reality as valid while transposing ourselves within the other. The key here is I hold your words with a reverence and respect not usually granted to language. Doing this insures us sharing a “common language” and “being on the same page”.
Language is a reflection and creation of culture. As such, language influences how culture sees psychotherapy. For example, with managed care insurance using the language of science to legitimize reimbursement, sterile words such as “patient”, “treatment”, and “diagnosis” have become the norm. In the modern era, language was seen as merely describing Reality; in the post-modern era, language plays a larger part in creating the Reality itself. The process of psychotherapy is not immune from the world-view, where due to managed care requirements therapists use non-therapeutic language to conceptualize the process of their work. It is imperative that therapists acknowledge the relationship between language and power: parties who control language also control Reality (and vice-versa) and therefore have power. At the risk of sounding alarmist, it is dangerous for therapists to relinquish their personal voice, to abandon their words in favor of dehumanizing insurance jargon which has an investment in nothing other than saving money. For an insurance company, the bottom line always to limit claims payments, and this is directly at odds with the calling of a therapist – to heal a human being. Ultimately, our words about psychotherapy must be in service of the client.
Safety is the most unsafe path you can take, safety keeps you numb and dead. People are caught by surprise when it is time to die. They have allowed themselves to live so little.
– Stephen Levine
Ethics / Moral Principles in Psychotherapy
The underlying principles therapists adhere to in doing psychotherapy are:
- FIDELITY: Fidelity involves issues of loyalty, faithfulness, and promise-keeping – these are essential for trust and honest communication between client and therapist. According to research on effective therapy outcomes, a good therapeutic relationship is highly correlated with positive change – this is true across multiple counseling methods. A positive alliance reported by the client is the strongest predictor of outcome.
- JUSTICE: In its broadest sense, this is “fairness” and the foundation for therapists to treat all clients “equally well”. For example, an ethical therapist does not treat a sliding scale client differently from a full fee client; both clients should expect and receive the same treatment, consideration, and logistical conveniences, regardless of the fee he/she is paying.
- AUTONOMY: Each client, as an autonomous person, has freedom of choice and responsibility for decision-making and behavior. The concepts of unconditional worth and tolerance for individual differences reflect therapists’ respect for clients to make their own decisions. This principle of autonomy is also the basis of the right to privacy and confidentiality.
- BENEFICENCE: This involves therapists’ commitment to contributing to the health and welfare of clients; mental health professionals are members of the “helping professions”, reflecting the obligation to promote positive growth.
- NONMALEFICENCE: This is a concept rooted in medicine meaning “above all, do no harm”. Therapists are responsible for knowing what attitudes, behaviors, etc. have potential to cause harm. Specific applications of this principle include: not misusing assessment results, respecting clients’ civil rights, practicing only within the boundaries of the therapist’s competence, maintaining competence and furthering knowledge through continuing education/proactive learning, avoiding dual relations, etc.
An example of the “do no harm” principle is therapists setting boundaries, e.g. avoiding dual relationships. Therapists recognize that dual relationships erode and distort the professional nature of therapy. Even after termination, there are three reasons why the therapeutic relationship does not end: 1) It is the therapist’s continued responsibility to maintain confidentiality, release notes, etc.; 2) Client and therapist may still occasionally contact each other; and 3) The client typically internalizes the therapist.
Common dangers of dual relationships are:
- Role-theory explains that social roles contain inherent expectations about how a person in a particular role is to behave, as well as the rights and obligations pertaining to that role. Role conflicts arise when the expectations attached to the one role, call for behavior that is incompatible with another role.
- If the therapist is also the client’s friend, employee or employer, landlord, etc. the crux of the therapeutic relationship is no longer healing and the nature of the interaction is compromised.
- A dual relationship creates a conflict of interest so that the intentions and investment of client and therapist are distorted.
- Dual relationships negatively affect the cognitive and emotional processes that research has shown to play in the beneficial effects of therapy, e.g. recalling positive memories of therapy and internalizing the therapist’s voice.
- The power differential inherent in client and therapist roles prevents the client from entering into another egalitarian relationship with the therapist; the power dynamic here is also related to the therapist being privy to intensely personal information about the client.
- The fundamental nature and sanctity of psychotherapy would be changed if the therapy office became a place to meet friend, lovers, business partners, social contacts, etc.
- If the therapist has an additional secondary relationship with the client, testimony and reports in courts, schools, and other forums would be compromised.
Consider these definitions:
- Privacy: The right to decide how to live one’s own life. Constitution of the United States; Article 1, Section 1 of the California Constitution; Information Practice Act of 1977
- Confidentiality: The client’s right to have communications kept within the bounds of the professional relationship. The California legislature provides a comprehensive right to privacy, covering all medical relationships and patient communications. your right to privacy is absoluteThis is the Confidentiality of Medical Information Act (CMIA), where all health service providers must maintain the confidentiality of all medical information (Civil Code 56 and Welfare and Institutions Code 5328).
Your right to privacy is absolute – the value underlying privacy reflects our society’s belief in individual autonomy, that we have a right to live our lives as we choose, given that our choices do not harm others in a shared society. Confidentiality is a subset of this overarching privacy principle. Confidentiality guarantees that you are free to decide for yourself with whom you share what is most personal to you. You have the legal and ethical right to expect your therapist to maintain utmost confidentiality; without your explicitly written consent your therapist cannot share your information with anyone. In keeping all communications confidential, the therapist treats clients with respect and dignity, paving the way for building trust in the therapeutic relationship. Trust is the foundation for you and your therapist to work on mutually agreed upon goals. It is crucial for you to know and trust that everything you say to your therapist is kept private, your feeling that your discussions are kept safely contained is key for effective psychotherapy.
There are some legal exceptions to confidentiality when, in the interest of society, a mental health professional has a duty to disclose what the client reveals. If, in the course of treatment, the need to disclose information arises, your therapist should be up front and honest about it, discussing with you in advance his/her intention to disclose specific content. You should not have to be unpleasantly surprised that your therapist has shared information.
The exceptions are:
- If abuse/neglect of a child, elder, or physically/mentally handicapped person is occurring
- If you are a danger to yourself or others, the therapist is required to report this to the appropriate authorities.
- If you want your therapist to communicate with another professional about your treatment, e.g., your M.D.
- Third party insurance payment – your therapist may be required to give diagnoses and/or treatment information so that you get reimbursed. You have the right to expect that your therapist will discuss beforehand with you the details to be shared with your insurance company.
- In the event of a malpractice case, e.g. if a client sues the therapist, the therapist may disclose details of treatment for the purpose of defense.
- The Patriot Act of 2001 (Section 215) requires therapists and others to provide the FBI with information related to an investigation to protect against international terrorism or clandestine intelligence activities. The Act also prohibits therapists from disclosing to clients that the FBI sought such information.
Confidentiality and Group Therapy
Therapists treating clients in a group typically develop a group confidentiality agreement where not only is the therapist’s duty of confidentiality to the group established, but also each group member agrees to keep all information in session confidential – this would be a condition for participation in the group.
Confidentiality and Conjoint Couples Therapy
The therapist typical adopts a “no secrets” policy where the therapist will not allow him/herself to be put in the position of holding the secret(s) of a client in couples therapy. Each member of the couple should be informed of and agree to this policy. Couples therapy cannot be effective (and may be destructive) if either or both clients find out the therapist has been privy to information from their partner and has been in collusion with their partner. In such a scenario, it would be a profound betrayal by the therapist of the client. Ideally, a conjoint confidentiality agreement would state that the therapist may disclose relevant information to both partners at the therapist’s discretion. An example of doing couples therapy without the “no secrets” policy: if a client tells the therapist in a private session that he/she is having an affair and/or planning to leave the partner, it would be unethical and counter productive for the therapist to continue to work with the couple knowing that one partner is not honest and has a hidden agenda.
Confidentiality and Third Parties Who Attend Therapy
When clients bring visitors to one or a few of their therapy sessions, e.g. relatives and friends, the therapist should inform the visitor the he/she is welcome to attend the session but is not considered a client and therefore is not entitled to confidentiality under the law. Obviously, the therapist will respect the confidential nature of the sessions(s), but the visitor should not expect to receive the same legal protection received by the client.
The Role of Medication
The intersection between biology and psychology is multi-dimensionally complex, and the decision to take medication is a highly personal one. Certain conditions require medications while other symptoms respond best to psychotherapy. Further still, some problems do well with a combination of both. For example, if you are having visual and/or auditory hallucinations (seeing/hearing things that are not there), medication is appropriate. If you’re having problems with work, family, etc., feeling down about yourself or struggling with self-doubts, psychotherapy works well. If however, you’re going though major clinical depression where it’s hard to get out of bed an bathe, or have panic attacks leading to ER visits for chest pain and dizziness, or severe obsessive-compulsive symptoms such as washing hands 50 times a day, both therapy and medication are ideal. Although medication can provide huge symptomatic relief, it is never a substitute for therapy because medication alone cannot address the underlying reasons for the symptoms. For example, an anti-depressant will help a mildly depressed man regulate better sleep/appetite and restore more pleasure in his life, but it will not fix his long-standing tendency to criticize himself. Similarly, and anxiolytic agent will ease the anxiety of a woman in a volatile, destructive relationship, but it will not resolve her chronic pattern of becoming involved with emotionally abusive and unavailable men.
On principle alone, I am neither pro nor con medication. It can be as useful for one client as it can be useless for another – everybody is unique, and every case needs thorough, careful, consideration. If we decide that medication may be indicated for you, I am happy to work with a psychiatrist or internist on your insurance plan. If you do not have one, I can refer you to a psychiatrist for medication assessment, prescription and management. With your consent, I prefer to regularly communicate with your practitioner to insure you’re receiving coordinated care.